Open surgical treatment of a fracture involving the phalanx or phalanges of the great toe, with internal fixation applied when clinically indicated.

Verified May 8, 2026 · 4 sources ↓

Medicare: $668.35
Total RVUs: 20.01
Global, days: 90
Region: Foot & ankle

Drawn from CMSEmednyAAOS

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 4 cited references ↓

Operative report must confirm open approach with skin incision and direct fracture visualization — not percutaneous technique.
Identify which phalanx (proximal, distal, or both) was treated and laterality (right or left great toe).
Document whether internal fixation was used; if so, specify implant type (K-wire, screw, plate) and placement.
Imaging (pre-op X-ray or fluoroscopy) confirming fracture diagnosis and post-reduction position.
Specify any complicating factors (comminution, open fracture, failed prior closed treatment) if billing modifier 22 for increased complexity.
Anesthesia type and estimated blood loss documented in the operative note.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 58 Staged or related 59 Distinct service 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 4 cited references ↓

28505 covers open treatment of a great toe phalanx fracture — meaning the surgeon makes a direct incision to access and reduce the fracture. Internal fixation (pins, screws, K-wires) is included in the code when used; you don't bill it separately. The great toe has two phalanges (proximal and distal), and this code covers either or both when treated in the same operative session.

This code sits at the top of a three-tier ladder for great toe phalanx fractures: 28490 (closed, no manipulation), 28495 (closed, with manipulation), 28496 (percutaneous fixation), and 28505 (open). Choosing the wrong tier is the most common coding error on these claims. Open treatment requires skin incision and direct visualization — percutaneous pinning without a formal open approach belongs at 28496.

The 90-day global period means the surgery, the day-before visit, and all routine post-op care through day 90 are bundled. Casting or splinting applied at the time of surgery is included and cannot be billed separately. If the same surgeon performs an unrelated procedure in that window, append modifier 79. Casting applied as the only initial service — when no definitive procedure follows — is a different scenario governed by NCCI Chapter 4 rules.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	7.25
Practice expense RVU	11.81
Malpractice RVU	0.95
Total RVU	20.01
Medicare national rate	$668.35
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$668.35
HOPD (APC 5113) Hospital outpatient department	$3,342.87
ASC (PI A2) Ambulatory surgical center (freestanding)	$1,644.87

Common denial reasons

The recurring reasons claims for CPT 28505 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Wrong code tier selected — percutaneous fixation billed as open treatment (28496 vs. 28505).
Missing laterality modifier (LT or RT); many payers and NCCI flag toe procedures without a digit or side modifier.
Casting or splinting billed separately on the same date — bundled into 28505 when the surgeon assumes follow-up care per NCCI Chapter 4.
ICD-10 diagnosis code does not support open treatment (e.g., non-displaced fracture coded without documentation of failed closed management).
Procedure billed during the global period of a prior related foot surgery without modifier 79.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 4 cited references ↓

01When should I use 28505 versus 28496?

28496 is percutaneous skeletal fixation — pins inserted through intact skin without a formal open incision. 28505 requires a skin incision and direct visualization of the fracture. The operative note has to support whichever code you select; auditors specifically look for this distinction.

02Do I need a laterality modifier on 28505?

Yes. Append LT or RT to identify which foot. NCCI policy for toe procedures also recognizes digit modifiers (TA for the left great toe, T5 for the right great toe), and some payers require them. Check your payer contracts — Medicare accepts both LT/RT and TA/T5 for toe procedures.

03Can I bill for casting or splinting applied at the time of open treatment?

No. Per NCCI Chapter 4, when a physician performs a definitive fracture procedure and assumes follow-up care, casting and splinting codes are bundled. Do not bill them separately on the same date as 28505.

04Is internal fixation billed separately from 28505?

No. Internal fixation is included in 28505 when performed. There is no add-on code to separately bill pins, screws, or K-wires used during this procedure.

05How does the 90-day global period affect same-day E/M billing?

A significant, separately identifiable E/M on the day of surgery requires modifier 57 if the decision for surgery was made at that visit. Modifier 25 applies to a separate E/M on the same day for a different problem. Routine pre-op assessment within the global is not separately billable.

06Can 28505 be billed bilaterally?

Yes, with modifier 50 if open treatment of great toe phalanx fractures is performed on both feet in the same operative session. Bill as a single line with modifier 50 per CMS claims processing rules. Reimbursement is subject to the bilateral surgery payment reduction.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the surgical approach (open vs. percutaneous), which phalanx was fractured and reduced, whether internal fixation was placed and its type, and explicit laterality from the dictation. This prevents the most common audit flag on 28505 claims: an operative note that doesn't clearly distinguish open treatment from a percutaneous technique, which triggers downcoding to 28496.

See how Mira captures CPT 28505 documentation